May 24, 2017 - Official Full-Text Paper (PDF): Quality Assurance in Nursing.
Book Reviews
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though one of the authors, Adam Darkins, is surely fantasizing that "five years from now we will all expect decision support when we look at treatment choices" - ten or fifteen years, maybe. A workshop on models of lay participation yielded some very germane points. And improving the communication that takes place through the media is certainly necessary; in May 1994 alone the National Asthma Campaign has had to pick up the pieces of a huge "steroids scare" perpetrated by The People, and explain to caller after caller that "the asthma gene" has not in fact been found, as the newspapers would have them believe. But why does the report have to be so loaded with jargon? Do any of us actually like being called a "healthcare consumer" when we are ill? Why call the conference, "Involving Users of Health Services in Outcomes Research" instead of, "Asking Patients What They Want?" If those who organise and deliver care really want patients to help to make themselves better the first thing they need to do is to learn to speak in plain English. MELINDA LETTS Chief Executive, National Asthma Campaign
But We are Different ... Quality for the Service Sector. John Macdonald (pp 213; £16.95 hardback). Didcot, Oxfordshire: Management Books, 1994. ISBN 1-85251-131-1. It might seem impertinent to write a review and suggest that we write and talk less about quality in health care and more about the real nature of the health business so that we can understand more about what really needs to be done. I can disagree with nothing in this book; what concerns me is what it doesn't deal with and its rather superficial and simplistic analysis of the issues. I doubt its influence on quality in the service sector (sic). Let me try and explain why. John Macdonald is right when he questions the reluctance of the service sector to learn the lessons from the manufacturing sector. What is less clear is whether he also appreciates and values the distinctiveness of the service sector. It seems to me that by grouping financial services, the civil service, retail trade, local authorities, the transportation industry, the NHS, management consultants, education, and hotel and catering together in this apparently haphazard way he fails to demonstrate the essential nature of these various industries and the organizations that support them. This is not to say that each should learn from each other, just as each should learn from the manufacturing sector, but that simply transferring learning will have little impact. Two obvious organisational issues differentiate public service industries - the health service; education; social services; and others, like the prison and probation services: first there is a permanent dilemma in trying to meet the needs of the individual and the wider community simultaneously and second the service that people receive depends on the relationship between a professional doctor, teacher, social worker, prison officer - and the individual user. These
issues make the simple translation of methods that are effective in other sectors fail in these unique public service industries. A third issue, the prevalence of institutionalized care that characterizes these public service industries, adds yet another dimension. Anyone who has worked in a hospital, a home for older people, a school, or a prison will be deeply aware of the effect of institutionalisation on users and staff alike. NHS readers of this book will be wary of the paucity of its analysis of the nature of health care and rightly sceptical of the cheery solutions. Anybody who has read the Ritchie report into the treatment and care of Christopher Clunis will understand readily that while TCI (see below) will keep a lot of people engaged in time consuming activity it will hardly address the profound and endemic problems that pervade all the services that are designed to support, care for, and treat people with mental illnesses. I just might be shroud-waving, claiming on behalf of these services, "But we are different ... " You may judge for yourselves, but the notion that health services are analogous, in managerial terms, to making "widgets" or even to Macdonalds is a myth that has been around for over ten years and needs to be put to rest. TQM and TCI (you will have to read the book to know what it means) will not address the fundamental issues that an organisation like the NHS is facing; they could help, but not where the business happens. We need to get back to understanding the nature of the health business.
JOHN MITCHELL Consultant, Mitchell-Damon
Quality Assurance in Nursing. Heather Marr, Hannie Giebing (pp 139; £9.95). Edinburgh: Campion Press, 1994. ISBN 1-873732-04-X. Most contemporary nursing courses include instruction in the philosophy and methods of quality assurance. This text is aimed primarily at those nursing students undergoing Project 2000 diploma courses. It may also be used as an introductory text for qualified nurses who wish to develop an awareness of standard setting and audit. The core content of the book principally centres around the theory and application of the Dynamic Quality Improvement (DQI) system (formally DYSSSY) as formulated by Kitson and others. Students from other healthcare disciplines may find the book a useful introduction to the DQI system. There are several other texts competing for this market niche. However, they invariably are broad in their description of the various quality assurance approaches available in nursing. In contrast, this book demonstrates the "why and how to" of a well researched quality improvement approach, and here lies its strength. Its other merits include the simplicity of its descriptions and the fact that all chapters contain explicit learning outcomes and study activities for the reader. The book is divided two parts: the first focuses on what quality is and how nurses can assure and improve quality, placing considerable emphasis on empowering
practitioners to take responsibility for the quality of service they provide, the second provides seven factual examples of how the DQI system was applied to practice. Potential readers must be acutely aware of what this book offers. If they wish to increase their knowledge concerning other quality assurance approaches in nursing (for example, Monitor, QualPACs), or recent developments in quality assurance computer software or multidisciplinary quality initiatives they will have to look elsewhere. In conclusion, the authors set out to write a book that introduces nurses to the principles and practices of a quality improvement approach. I believe they have succeeded. They have produced an inexpensive, elementary, and understandable text which should be an attractive purchase for the quality assurance neophyte who requires guidance in an increasingly complex field.
HUGH McKENNA Lecturer in Nursing
Palliative Care in Terminal Illness. 2nd ed. J F Hanratty, I Higginson, eds (pp 128; £12.50). Oxford: Medical Press, 1994. ISBN 1-85775-030-6.
Sitting down with this book, I recollected a consultation I witnessed as a medical student twenty years ago. A middle aged patient had come for the results of a bronchoscopy done six weeks previously. The physician said, "I'm sorry to tell you that you have incurable lung cancer and there's nothing anyone can do to help you." The patient gulped and left, and the consultant turned to me and said, "I always find it best to be frank in these cases." On the second page, I found a similar
experience of bleak helplessness towards the hopeless case described by the authors, and from then on the book rang true. Although based on experience in the hospice setting, this overview of progress in palliative care over the past two decades is helpful and relevant to all those involved in care of the dying in hospital or the community. People with terminal incurable illness have various physical, social, spiritual, and practical problems, and the challenge is to relieve discomfort, enhance wellbeing, and foster realistic hope that good quality life may be enjoyed until the end. Carers do not need exceptional counselling or psychiatric skills, but rather sensitivity to the patients needs and wishes, sympathy combined with pragmatism. Palliation is sometimes perceived, wrongly, as placebo, but in fact many active measures are available to alleviate distressing symptoms. The management of dyspnoea, for example, includes practical advice - on sleeping upright; using a cool fan; taking drug treatments such as opiates, nebulised bupivicaine; and encouragement to try the unorthodox - diazepam. Common sense helps cachexia is less of a problem if it is explained that force feeding and focusing attention on food will merely serve to make the patient uncomfortable, and will not prolong life. Caring for the population of patients with AIDS presents unique problems, as
